Stella Maris, Inc.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews with staff, and review of complaint, it was determined that the facility failed to store food and monitor temperatures in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: 1. The facility staff failed to ensure food is served to residents at temperatures to ensure food safety. On 4/8/25 at 12:29 PM the Surveyor observed lunch meal service to the Residents on the 1 [NAME] nursing unit. At that time the facility staff were setting up meal service and residents were seated in the dining room. After the residents were all served in the dining room the facility staff began to prepare trays for residents who dine in their room at 1:06 PM. At that time the Surveyor requested a test tray and took temperatures. At the same time Staff #36 also took temperatures of the same test tray using a facility's thermometer. Hot foods are to be maintained…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility's and vendor's pest control logs and interviews, the facility failed to maintain an effective pest control program. This was evident for 3 of 8 nursing units (1P, 3P and 3S) and the kitchen during a complaint survey. The findings include: During investigation of multiple complaints from resident families regarding mice sightings in the facility on nursing units 1P, 3S and 3P, the surveyor reviewed on 4/7, 4/8 and 4/9/25 the facility's and vendor's pest control logs from 1/1/25 until 4/8/25 and completed interviews. 1. Review of the facility's pest control logs revealed the following: a) On 1/10/25 facility staff stated they disposed of a dead mouse in room [ROOM NUMBER] last evening b) On 1/30/25 facility staff stated moving recliner chairs in Rooms 315 & 324 there were a lot of mouse droppings. c) On 3/7/25 facility staff stated night nurse stating residents complaining about mice in rooms. d) On 4/4/25 facility staff stated residents states seeing 2 mice in room [ROOM NUMBER]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, the facility staff failed to obtain consent from the Resident's representative prior to administering a new medication to a resident (Resident # 33). This was evident for 1 of 71 residents reviewed during a complaint survey. The findings include: Review of Resident #33's medical record on 3/27/25 the Resident was admitted to the facility in September 2023 with a diagnosis to include dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life. Further review of Resident's medical record revealed the Resident was seen by the Psychiatric Practitioner (Staff #70) on 9/18/23 and at that time Staff #70 ordered Depakote 125 mg twice a day for dementia with behavioral disturbances. Depakote is a medication that can treat seizures and bipolar disorder. Staff #70 documented at that time unable to reach resident's representative to discuss progress and plan. Further review of Resident #33's medical record revealed the facility staff assessed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, it was determined the facility staff failed to notify the physician of the inability to obtain an opthamology consult. This was evident for 1 (#7) residents reviewed for 40 complaints reviewed during a complaint survey. The findings include: On 3/31/25 at 8:34 AM a review of complaint MD00212199 was conducted. The complainant alleged that Resident #7 was hit by his/her aide. The complaint alleged Resident #7 had a bruise on his/her face from the incident. Review of a 11/22/24 at 2:30 PM SBAR (change in condition note) documented, around 0815 writer was called to room by GNA. GNA had just walked into the room and noticed bruising to left peri-orbital region with a small gash to left eyebrow. Resident initially stated that [he/she] was hit with a dish. Then stated that [he/she] was turned over (in bed) and hit [his/her] head. A 11/22/24 at 7:11 PM provider note documented, Note: Patient noted with left periorbital swelling, erythema, tenderness and hematoma extending towards nasal bridge and inner canthus of left eye. The assessment and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of a facility reported incident with documentation, medical record review, and staff interview, it was determined the facility failed to protect a vulnerable adult from physical abuse. This was evident for 1 (#34) resident reviewed for 27 facility reported incidents reviewed during a complaint survey. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facility's plan and action were verified during this survey; therefore this deficiency was found to be past noncompliance with a compliance date of 10/16/23.The findings include:On 3/27/25 at 3:03 PM a review of facility reported incident MD00198080 alleged that on 10/5/23 at approximately 9:00 AM, GNA #16 was providing morning care to Resident #34. Resident #34 was swinging his/her arms at GNA #16, and LPN #15 witnessed the interaction. According to GNA #16, LPN #15 came running in the room, got close to Resident #34, then walked back to close the door. LPN #15 came back rushing and slapped Resident #34 in the face hard on the right side at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#30, #24, #15, #29) of 71 residents reviewed during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 3/31/25 at 10:00 AM Resident #30's medical record was reviewed and revealed a 2/2/24 progress note that documented Resident #30 had an unwitnessed fall and was bleeding from the head. Resident #30 was sent to the emergency room and returned to the facility on 2/3/24 at 5:30 AM. Resident #30 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview it was determined that the facility failed to have a process in place to ensure that a baseline care plan was provided to the resident and resident representative within 48 hours of admission to the facility (Resident #33 and #65). This was evident for 2 of 71 residents reviewed during a complaint survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1. During interview with Resident #33's representative (RP) on 4/2/25 at 10:12 AM, the RP stated he/she was never given a baseline care plan or had a meeting with the facility staff to discuss. Review of Resident #33's medical record on 4/2/25 revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and staff interview it was determined that facility staff failed to develop and a comprehensive, resident centered care plans for altered skin integrity. This was evident for 1 (#30) of 71 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 3/31/25 at 10:00 AM a review of complaint MD00201834 alleged that Resident #30 received a pressure ulcer due to care issues in the facility. Review of Resident #30's medical record revealed a 1/6/24 progress note that documented Resident #30 had erythema noted to the bilateral buttocks and a rash to the bilateral upper/posterior thighs. An anti-fungal powder was ordered Review of Resident #30's January 2024 Medication Administration Record (MAR) documented the order, in house antifungal powder to posterior upper & inner thighs BID (twice per day) until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment and care in accordance with professional standards of practice. This was evident for 3 (#5, #38, #14) of 71 residents reviewed during a complaint survey. The findings include: 1. The facility staff failed to administer medications to Resident #5 as ordered by the eye doctor. Review of Resident #5's medical record on 4/3/25 the Resident was admitted to the facility in December of 2024 with a diagnosis to include legal blindness. Further review of Resident #5's medical record revealed the Resident went to the Eye Doctor on 2/7/25 and at that time was assessed to have a diagnosis of Glaucoma, Entropion and dry eye. Glaucoma is a group of eye diseases that damage the optic nerve, potentially leading to vision loss or blindness, often due to increased eye pressure. Entropion is a condition where the eyelid turns inward, causing eyelashes to rub against the eye, leading to irritation, pain, and potentially, corneal damage. Dry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to provide treatment/services to prevent/heal pressures ulcers (Resident #55). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey. The findings included: A pressure ulcer also known as pressure sore or decubitus ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Pressure ulcers are staged according the their severity from Stage I (area of persistent redness), Stage II ( superficial loss of skin such as an abrasion, blister or shallow crater), Stage III ( full thickness skin loss involving damage to subcutaneous tissue presenting as a deep crater), Stage IV (full thickness skin loss with extensive damage to muscle, bone or tendon) or Unstageable Pressure Ulcer (full thickness tissue loss in which the base of the ulcer is covered by slough and / or eschar in the wound bed). A deep tissue injury (DTI) is a unique form of pressure ulcer. The National…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, facility policy review and interview, the facility staff failed to obtain weekly weights on admission and failed to recognize a weight loss for a resident (Resident #33). This was evident for 1 of 71 residents reviewed during a complaint survey. The findings include: Review of Resident #33's medical record on 3/27/25 documented the Resident was admitted to the facility in September 2023 with a diagnosis to include dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life. Further review of Resident's medical record revealed the facility staff documented a nutritional assessment was completed on 9/19/23. At that time the Dietitian (Staff #72) documented, intake is fair presently-weekly weights initiated to evaluate additional intervention. Review of the Resident's weights documented revealed the facility staff documented a weight on 9/27/23 of 232.8 pounds and on 10/17/23 of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of a complaint, medical record review, and interview, it was determined the facility failed to provide timely medication to meet the needs of the residents. This was evident for 1 (#14) resident reviewed for 40 complaints reviewed during a complaint survey. The findings include: On 3/27/25 at 1:15 PM a review of complaint MD00210066 alleged that there was a problem with the A&D ointment that was ordered for Resident #14. It was alleged that the ointment was received however the staff was not consistent with using the ointment and then kept telling the resident it was not available from the pharmacy and had been re-ordered. Review of Resident #14's medical record revealed an order for A and D Prevent External Ointment that was to be applied to the perineal area topically every shift for skin protectant with each incontinence care. The start date of the order was 9/1/24. Review of the September 2024 Medication Administration Record (MAR) documented each time the ointment was administered as evidence by the nurse's initials and a check mark. Whenever there were nurse's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and documentation review it was determined that facility staff failed to keep medication carts locked when unattended and date medications when opened. This was evident on 3 of 7 nursing units observed during random observations made during the complaint survey. The findings include: 1) On 4/2/25 at 9:48 AM observation was made on the 1 Knot unit of an unlocked medication cart sitting outside of room [ROOM NUMBER]. The surveyor was able to open the top drawer of the medication cart which contained resident medications. Licensed Practical Nurse (LPN) #32 stated she had just walked into the resident's room for a minute. 2) On 4/2/25 at 10:08 AM observation was made on the 1P unit of an unlocked and unattended medication cart at the nurse's station. The surveyor walked up and opened the top drawer. The surveyor had previously seen the medication cart sitting at the nurse's station unlocked with LPN #22 sitting at a computer at the nurse's station and unit secretary #28 sitting…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to obtain laboratory services for a resident as ordered (Resident #33). This was evident for 1 of 71 residents reviewed during a complaint survey. The findings include: Review of Resident #33's medical record on 3/27/25, the Resident was admitted in September 2023 with a diagnosis to include dementia. Dementia is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life. Further review of Resident #33's medical record revealed on 11/17/25 the Nurse Practitioner (Staff #71) ordered a c diff sample. To test for C. difficile, a stool sample is collected and sent to a lab for analysis, where they look for the presence of the bacterium and its toxins. Further review of Resident #33's medical record revealed a change of condition note on 11/22/23 at 6:50 PM that stated Resident's representative visited him/her at bedside at 2 PM today and requested he/she be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, the facility staff failed to obtain outside services for residents in a timely manner. This was evident for 2 (#5, #7) of 71 residents reviewed during a complaint survey. The findings include: 1. Review of Resident #5's medical record on 4/3/25 the Resident was admitted to the facility in December of 2024 with a diagnosis to include chronic kidney disease. Further review of the Resident's medical record revealed on 12/10/24 the physician ordered a nephrologist consult for chronic kidney disease stage IV. Further review of the medical record revealed the Resident has not been seen by the nephrologist or has a appointment scheduled. Interview with the Director of Nursing and Assistant Director of Nursing on 4/7/25 at 2:09 PM confirmed the facility staff failed to schedule an appointment for Resident #5 to see a nephrologist.2. The facility failed to obtain an ophthalmology consult as requested by the Nurse Practitioner (NP) for a resident with orbital bruising and swelling. On 3/31/25 at 8:34 AM a review of complaint MD00212199 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #20). This was evident for 1 of 71 residents reviewed during a complaint survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Review of Resident #20's medical record on 4/3/25 revealed the Resident was admitted to the facility in August 2023 and admitted to hospice services on 6/20/24. Further review of the Resident's medical record revealed no documentation from hospice to include progress notes, assessments and plan for Resident #20 from hospice. Interview with the Director of Nursing (DON) on 4/4/25 at 12:54 PM confirmed Resident #20's medical record did not include documentation from hospice and the DON was able to obtain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on complaint review, observation, and staff interviews it was determined that the facility failed to implement an effective infection control program by failing to follow infection control guidlines during the handling and storage of linens and other patient care items. This was evident for 2 of 7 units observed during random observations made while touring the facility during a complaint survey. The findings include: On 3/31/25 at 7:40 AM a review of complaint MD00214733 revealed the facility did not follow infection control guidelines. On 4/2/25 at 9:32 AM observation was made on the 1 Knot unit, outside of room K188, of a soiled linen cart. On top of the soiled linen cart was a box of gloves, cleanser, silicone cream ointment, and an opened Pepsi bottle. There was also a list of resident names with names and weights. There was a pink pen next to the paper. The patient care items were not stored properly. Observation was made in the hallway, across from 1K, room K180, of a resident's over the bed tray table with clean linen, sheets, towels, and diapers sitting on top of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff interview it was determined that the facility staff failed to accurately code the resident's status on the Minimum Data Set (MDS) assessment (Resident #176, #242, #288, #310, #298, #381 and #290). This was evident for 7 out of 89 residents selected for review during an annual survey. The findings include: The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. 1. Review of Resident #176's medical record on [DATE] revealed the Resident was admitted to the facility on [DATE] with a diagnosis to include chronic obstructive pulmonary disease (COPD). COPD refers to a group of diseases that cause airflow blockage and breathing-related problems. Observation of Resident #176 on [DATE] at 8:45 AM and [DATE] at 8:35 AM revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review it was determined that the facility staff failed to initiate care plans for Residents #381, #279 and #685. This was evident for 3 of 89 residents selected for review during the annual survey. The findings include: A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost. Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client's changes in condition and evaluation of goal achievement. 1 A. The facility staff failed to initiate a care plan to address high blood pressure. Medical record review for Resident #381 on 5/6/22 at 11:00 AM revealed the resident was admitted to the facility with diagnosis that include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. The facility staff failed to notify the physician or certified registered nurse practitioner (CRNP) of elevated blood pressures as ordered by the physician. Medical record review for Resident #6 on 5/4/22 at 9:30 AM revealed on 1/26/21 the physician ordered: blood pressure 2 times a day, notify the physician or CRNP for systolic blood pressure (top number) above 170. Medical record review revealed the following documented blood pressures: 4/2/22 (Monday) at 2:52 PM 178/72; 3/26/22 at 8:07 AM 184/74; 3/10/22 at 8:55 AM 180/72; 1/29/22 at 8:32 AM 191/65, 1/21/22 (Friday) at 10:20 AM 183/73; 1/8/22 at 9:00 AM 202/79; 12/8/21 (Wednesday) at 9:25 AM 183/66; however, the facility staff failed to notify the physician or CRNP of the blood pressures as ordered. The resident is in dialysis on Tuesday, Thursday, and Saturday. Interview with the Director of Nursing on 5/5/22 at 8:00 AM confirmed the facility staff failed to notify the physician or CRNP of elevated blood pressures as ordered. Interview with the Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews with residents and facility staff, the facility failed to serve residents food which was palatable and did not serve food at the preferred temperature. This was evident for 3 of 89 residents (Residents #132, #158 and #316) selected for review during the survey process. The findings include: During observation of the facility staff serving breakfast on 4/20/22 at 8:55 AM, the Surveyor observed the facility staff serving breakfast in plastic containers from a hot table in the dining room. The facility staff then would distribute the plastic containers to all the residents on the unit that were eating in their rooms. A. During interview with Resident #158 on 4/19/22 at 11:10 AM the Resident stated often when he/she receives his/her meals the food is cold. Observation of Resident #158 on 5/3/22 at 9:48 AM revealed his/her breakfast was served in a plastic container containing 3 compartments. The Resident stated at the time it is hard to cut up meats with plastic silverware and in the small plastic containers. B. Observation of Resident #316 on 5/3/22…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interview, staff interview, and a review of community meeting minutes it was determined that the facility staff failed to act promptly upon the request of the residents regarding how meals are served. This was evident for one out of the six months reviewed. The findings are: This surveyor met with the residents on 5/2/22 at 2:00 PM as part of the mandatory Resident Council review task of the annual recertification survey process. The residents were interviewed, and they stated that they requested the facility return to serving meals on glass plates and providing metal silverware. The residents said the facility had implemented the use of plastic trays and plastic silverware because of COVID, but they would like a return to the previous method. The residents stated that concerns are raised at the community meetings each month. They sometimes get answers and sometimes they don't. A review of the December 30, 2021, community meeting minutes revealed that the residents requested a clarification on protocol for paper versus plastic usage for meals -- residents share it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, it was determined the facility staff failed to prevent verbal abuse from a Certified Medication Aid (#4) to Resident #279. This was evident for 1 of 2 residents selected for review of abuse during the survey process and 1 of 89 residents selected for review during the survey. The findings include: Medical record for Resident #279 on 4/20/22 at 10:30 AM and review of facility reported intake MD00169316 revealed the allegation that CMA#4 was observed by peers speaking loudly to Resident #279. It was also alleged CMA #4 pointing her finger and speaking unkindly to Resident #279. It was observed that the resident became tearful and upset. The CMA was removed from the facility and sent home. The resident stated that she/he felt better after the CMA was sent home and did not want CMA #4 to provide care to her/him anymore. Other residents were interviewed at that time and there were no other verbalizations related to care issues. The CMA #4 was terminated from the facility. Surveyor observation and interview with Resident #279 on 4/20/22 at 11:30 AM and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, it was determined the facility staff failed to honor the personal preferences interventions on the care plan for Resident #383. This was evident for 1 of 89 residents selected for review during the annual survey process. The findings include. A nursing care plan (NCP) is a formal process that correctly identifies existing needs and recognizes potential needs or risks. Care plans provide communication among nurses, their patients, and other healthcare providers to achieve health care outcomes. Without the nursing care planning process, the quality and consistency of patient care would be lost. Nursing care planning begins when the client is admitted to the agency and is continuously updated throughout in response to the client's changes in condition and evaluation of goal achievement. Medical record review for Resident #383 on 4/21/22 at 11:45 AM revealed the facility staff initiated a care plan for personal preferences for Resident #383 on 10/2/19: Personal Preferences: Things I don't like: I don't like loud noises, does not like her/his door closed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical review, it was determined the facility staff failed to prevent Resident #279 from receiving unnecessary medication. This was evident for 1 of 5 residents selected for review of unnecessary medications and 1 of 89 residents selected for review during the annual survey. The findings include: Medical record review for Resident #279 on 4/29/21 at 10:45 AM revealed on 6/16/21 the physician ordered: Lasix 20 milligrams by mouth every day for edema, hold for systolic blood pressure (top number) less than 110. Lasix is used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease. This can lessen symptoms such as shortness of breath and swelling in the arms, legs, and abdomen. This drug is also used to treat high blood pressure. Lasix is a water pill (diuretic) that causes the resident to make more urine which can lower the blood pressure. Medical record review revealed the facility staff documented the resident's blood pressure on: 3/21/22 as 100/67; 3/10/22 as 106/70; 1/27/22 at 101/70; 12/30 as 108/60 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and interview, the facility staff failed to obtain dental services for residents (Resident #242 and #288). This was evident for 2 out of 7 residents reviewed for dental services during an annual survey. The findings include: 1. Review of Resident #242's medical record revealed the resident was admitted to the facility on [DATE]. Observation of Resident #242 on 5/3/22 at 11:50 AM revealed the resident to have only 2 upper teeth that appeared to be broken and multiple broken lower teeth with obvious decay. During interview with the resident at that time, the resident stated he/she would like to see the dentist because his/her gums bother him/her at times and would like to be evaluated for dentures. Further review of Resident #242's medical record revealed the resident has not been seen by the dentist since admission to the facility. Interview with the Director of Nursing on 5/4/22 at 11:30 AM confirmed the resident has not been seen by dentist. 2. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, it was determined the facility staff failed to provide a meal to Resident #132 within the limited 14-hour time frame. This was evident for 1 of 6 residents reviewed for food during the survey process and 1 of 89 selected for review during the annual survey process. The findings include: Surveyor interview with Resident #132 on 4/20/22 at 12:00 PM revealed the resident stating that breakfast does not arrive to him/her until 10:00 AM. Review of the Dining Services Meal Delivery Times revealed that Unit 3S was to receive breakfast at 8:40 AM. Surveyor observations of Resident #132 revealed that breakfast was not served until 10:00 AM on 4/20/22 and 10:00 AM on 4/26/22. Further interview with Resident #132 revealed that no snacks are offered at night after dinner. Further review of the Dining Services Meal Delivery Times revealed that dinner is served to 3S at 5:00 PM. If taken into account an hour as for breakfast for the tray to be delivered to Resident #132, 6:00 PM and breakfast observed at 10:00 AM, there is a noted 16-hour span between meals and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview the facility staff failed to provide specialized rehabilitation services as ordered by the physician (Residents #316). This was evident for 1 out of 5 residents reviewed for rehabilitation services during an annual survey. The findings include: Review of Resident #316's medical record on 4/21/22 revealed the resident was admitted to the facility on [DATE] with diagnosis to include contracture right hand and acquired absence of right leg below knee. Further review of the resident's medical record on 5/3/22 revealed a physician order written on 4/19/22 for a consult with Occupational Therapy (OT) to evaluate for finger contracture and a consult with Physical Therapy (PT) to evaluate right prosthesis for friction rub-may need adjustment. During interview with Resident #316 on 5/3/22 at 9:05 AM, the resident stated he/she has not been evaluated by PT and OT for the consults ordered on 4/19/22. During interview with the Interim Director of Rehabilitation (DOR) on 5/4/22 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and interview, and observations it was determined the facility staff failed to maintain the medical record for Resident #132 in the most accurate and complete form. This was evident for 1 of 89 residents selected for review during an annual survey. The findings include: Medical record for Resident #132 on 4/20/22 at 10:45 AM revealed on 5/5/18 the physician ordered: thigh high teds on in AM. TED Stockings are also known as Compression Stockings or Anti-Embolism. TED Stockings are specially designed stockings that help reduce the risk of developing a blood clot in the lower leg. Surveyor observations of the resident on 4/21/22 at 10:00 AM, 4/25/22 at 1:00 PM, 4/26/22 at 10:30 AM, 4/29/22 at 12:30 PM revealed the resident in bed; however, ted stockings were not in place. Interview with resident during the visit on 4/21/22 revealed that the ted stockings are only put on when the resident gets out of bed (3 days a week). Interview with the Director of Nursing on 5/3/22 at 8:30 AM confirmed that the ted stockings are only put on the resident on days the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview it was determined the facility staff failed to administer the Influenza vaccine to Resident #337 per the request of the responsible party (RP). This was evident for 1 of 89 residents selected for review during the survey process. The findings include: Influenza is commonly called the flu. Influenza is a respiratory infection that can cause serious complications in older adults. Getting an influenza vaccine - though not 100% effective - is the best way to prevent the misery of the flu and its complications. Medical record review on 4/25/22 at 9:30 AM revealed Resident #337 was admitted to the facility 10/5/21. At that time, the resident's RP gave consent and requested that the resident was to receive the flu vaccine annually and completed the Immunization Consent Form. On 10/5/21 the physician ordered: Influenza Vac (vaccine) High-Dose Suspension Prefilled Syringe, Inject 0.7 ml intramuscularly (into the muscle) one time only for Flu Prevention. Review of the Medication Administration Record revealed the facility staff failed to document the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, document review and staff interview, it was determined the facility failed to ensure that: 1) the last annual survey was readily accessible to the public; and 2) identifying information regarding residents was not made available to the public. One of three recent surveys was missing from the survey book and 14 resident names were made public in one of three surveys in the survey book along with other private information. The list included the names of Residents #241; #88; #259; #471; #470; #36; #472; #474; #473; #69; #475; #42; #476; and #167. The findings include: 1) On 9/20/18 at 1:25 PM, the survey book located in the facility lobby was reviewed. Upon examination it was noted the results of the last annual survey were not in the survey book. The Code of Maryland Regulations (COMAR) 10.07.09.09 regarding the Implementation of Residents' [NAME] of Rights states a nursing facility shall post conspicuously in a public place accessible to residents: B (3) The nursing facility's statement of deficiencies for the most recent survey and any subsequent complaint…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility tour, observations and staff interviews it was determined the facility staff failed to ensure that rehabilitation medical records were kept in a confidential manner. This was evident in 2 out of 63 residents involving Residents (R) #139 and R #195 during the survey process. The finding includes: 1) On 9/18/18 at 3:00 P.M. on the first floor, 1 Panborn Long Term Care Unit, the surveyor observed on top of the standing unattended medication cart a medical referral for speech rehabilitation services forms faced up involving Resident #139 and Resident #195. It was on top of an empty anchor lap top pad holder attached to the medication cart. On those medical referral forms the surveyor was able to publicly view written orders for 1) Resident #195, the faxed completed form for speech rehabilitation services which contained the following: date, employee making referral, resident's name, room number, medical change of condition, medical summary for change of condition, a request order from the physician for a speech therapy evaluation and treatment, with the physician's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it was determined that facility staff failed to provide written notice of discharge to residents, resident's representatives and the Office of the State Long Term Care Ombudsman when residents were discharged from the facility. This was evident for three of 63 residents selected for review, Resident #s 272, 368 and 166. The findings include: 1) Resident # 272 was discharged to the hospital on August 11, 2018. Review of the resident's record and interview of the assistant administrator on September 21, 2018 at 11:41 AM verified that the required written notification had not been sent. 2) On 9/21/18 at approximately 3:30 PM, Resident #368's medical record was reviewed for a recent hospitalization. It was noted that on 8/10/18, Resident #368 was found unresponsive. The resident had been vomiting a brown coffee like substance. The resident was pale with a weak pulse and therResident's blood sugar was 435, and 452 after being given insulin. The resident was placed on oxygen and sent out to the hospital. During further review of the medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to ensure the physician's progress notes accurately documented the correct code status for one resident and weight requirements for another resident. This was evident for 2 of 63 residents investigated during the survey. The findings include: 1) On [DATE] beginning at 2:56 PM, the medical record for Resident #118 was reviewed. During the review it was noted that the code status was changed from Full Code to Do Not Resuscitate (DNR) on the Medical Orders for Life Sustaining Treatment (MOLST) form. The form was dated [DATE] and was signed by a Nurse Practitioner (NP). The NP also documented in progress notes dated [DATE] that the resident was a DNR per discussion. A provider progress note dated [DATE] stated the resident's code status is Full CPR (cardiopulmonary resuscitation). The physician's progress notes dated [DATE] still stated the resident's code status is Full CPR. On [DATE] at 2:14 PM, Unit Manager #1 was informed of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it was determined that facility staff failed to update a care plan for a resident for fall risk. This was evident for one (#157) of 63 residents selected for investigation. The findings include: On September 20, 2018, the care plan for Resident # 157 was reviewed for fall risks. The care plan is a document that outlines specific risks to a resident and provides information to staff to tailor care to the resident's needs. The care plan for Rresident # 157, last documented and updated on April 29, 2018, described the resident as a low risk for falls related to confusion, gait and balance problems and incontinence. Review of the resident's medical record, including the nurse's notes and provider (physician or nurse practitioner) notes revealed the following: On February 3, 2018, a Morse Fall Scale was completed for the resident and deemed the resident was at a high risk for falling. On November 3, 2017, the Morse Fall Scale evaluation showed the resident to be at a moderate risk for falling. Review of a Nursing Progress Note dated February…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview and documentation review it was determined the facility failed to ensurethat nursing staff followed proper hand hygiene while completing a treatment on Resident #260. This was evident for 1 of 2 residents observed while receiving dressing changes during the survey. The findings include: On 8/21/18 at approximately 10:00 AM while observing a dressing change for Resident #260, Staff nurse #2 was observed washing her hands and scrubbing for 8 seconds. When asked how long she should wash her hands, she said she remembered she should wash for as long as it takes to sing Happy Birthday. The Centers for Disease Control and Prevention (CDC) recommends in Hand Hygiene in Healthcare Settings, Techniques for Washing Hands with Soap and Water: >When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. >Rinse your hands with water and use disposable…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.